The National Training Programme in Laparoscopic Colorectal Surgery

Laparoscopic Colorectal Surgery (LCS) is a general term for operations on the colon and rectum through a minimally invasive access to the abdomen (keyhole surgery). There is rising evidence for superiority of such an approach in terms of postoperative morbidity and shorter hospital stay compared to traditional open surgery. It has been shown that LCS is safe for most tumour stages in the case of colorectal cancer. The collated evidence led to the NICE guidelines in 2006 recommending laparoscopic colorectal surgery as a preferable alternative to open surgery. It was estimated that a spread of LCS could provide substantial cost cuttings by reducing hospital bed days.

The National Training Programme (NTP) is an initiative by the Department of Health and the National Cancer Action Team that aims to train 250 specialists in colorectal surgery (consultant surgeons) to competency in LCS within five years in order to disseminate the technique. A structured and supervised training approach for these complex procedures is essential. However, little is known about the impact of different training modalities on learning advanced surgical procedures such as LCS. Existing evidence indicates that the technique in a self-taught approach is connected with elevated rates of adverse outcomes, which is no longer acceptable. The overall aim of the educational research, as reported here, is therefore to establish the evidence-base for the development of an academic educational platform that provides training and accreditation in laparoscopic colorectal surgery. Specifically, we aimed to:

Provide the educational structure and methods required for laparoscopic training courses
Conduct and coordinate the educational research between centres
Set up and validate the accreditation process following clinical training
Provide an educational evaluation of the pilot project
Raise patients and commissioners’ awareness of laparoscopic colorectal surgery.

The complexity of the process, the lack of evidence, and the need for applicability of research output dictates a multi-modality approach, encompassing systematic literature reviews, controlled experiments, surveys, interview studies, field studies and decision analysis. The main achievements to this day are listed below:

There is a need for a systematic and structured approach for training in LCS. A systematic review of the literature investigated the effects of mentoring (supervised training) on outcomes in LCS. The meta-analysis of morbidity and mortality data showed that trainees under supervision achieved the same results as expert laparoscopic surgeons. A direct comparison of supervised and self-taught trainees showed that self-taught surgeons experienced significantly higher rates of conversions to open surgery, which are known to cause more complications. The same review showed a a distinct lack of evidence on the effects of training modalities (courses with animal models, human cadavers and simulation) as well as on valid and reliable assessment methods for laparoscopic colorectal surgery.

A further systematic review on learning curves in LCS was carried out. There is only limited evidence on learning curves based on clinical outcome data. Using morbidity and mortality data for the description of a learning process leads to ethical dilemmas and suffers lack of precision.

A method for the monitoring of the training progression was developed and validated. The global assessment score (GAS form) was shown to be both reliable and valid for an estimation of the proficiency gain curve of the trainees. This method is currently being applied within the NTP to document individual training sessions and to identify trainees experiencing problems in their training progression.

A method for the final assessment and accreditation of the training was developed and is under validation. The “Laparoscopic Colorectal Competency Assessment Tool” (L-CAT) was developed for the signing-off process of trainees reaching the end of their supervised training period. L-CAT is a structured observational assessment tool for the evaluation of operating videos by expert judges. This tool was tested in an experimental setting and, again, shown to be reliable and valid to define competency.

Preferences for different training modalities were investigated. We surveyed attendants of training courses of their opinions using different training modalities – porcine, cadaveric, virtual reality and bench. Animal tissue was perceived to be of better quality and better tactile feedback with less odour and gas leak. In terms of anatomy, and port placement, more realistic operative conditions were achieved in the cadaveric model despite the lack of tissue perfusion.

Preferences of trainers and trainees could diverge. Direct comparison between the opinion of trainers and trainees attending either cadaveric or animal courses revealed that compared with trainees, trainers at cadaveric courses felt this was a better training model than the porcine model on account of the anatomy.

Preferences for immersion courses were investigated. A questionnaire was distributed to attendants of an immersion course, in order to ascertain the opinion of trainers and trainees. Preliminary data demonstrates that trainers believe that trainees would benefit from attending an animal course before operating on patients.

Rater dependences of assessment tools were investigated. Comparison of GAS form assessments performed by cadaveric course delegates, their peers and trainers demonstrate that trainees overate their ability to expose the operative field, underrate their mesorectal dissection skills, but their overall scores are almost identical to those given by their trainers. This suggests good insight to their abilities. Trainees’ peers tend to score them more highly.

Applicability of the GAS forms was investigated. Cadaveric course GAS forms for 10 delegates enrolled in the NTP showed a consistency in their scores achieved from the course GAS form and their first live operation of the NTP. A significant difference in scores was only found for the parts of the live operation which were performed by the trainer. This suggests that the GAS form is also an appropriate assessment form to use in the course setting to predict the performance in real life.

Objective evidence for the credibility of training modalities was piloted. The tissue compliance of porcine and fresh frozen human cadaveric intra-abdominal organs is being measured. This data will be able to provide an objective value of how realistic the tissue of these training models is.

A 3-D interactive educational platform was tested. An observational study has been performed to assess the value of live-links of laparoscopic colorectal surgery broadcast to a lecture theatre as part of an educational afternoon. This has been assessed with respect to the level of interactions, interruptions and opinion questionnaires. The study will be repeated but the live-links will be broadcast via Second Life, a media that enables users to interact with each other in a freely available online 3-D ‘metaverse’.

A method for the assessment of the surgical training technique is being systematically developed and will be tested in the field (STTAR - Surgical Trainer Trainee Assessment Report). The main themes have already been determined.

A consensus opinion of the attributes of a good laparoscopic surgical trainer and an expert surgeon is being systematically obtained. The main themes have already been determined.

The role of feedback in training advanced laparoscopic surgery is being determined. The main themes or its roles have already been outlined.